APPROACH TO PEDIATRIC

ABDOMINAL PAIN

DR GOKAH
GIDEON
GHANA POLIC
HOSPITAL
 Overview
 Introduction
 History
 Physical Examination
 Investigations
 Supplementary information
 General Presentation
Background
• Abdominal pain in a child is one of the most common presentations with both trivial
and
life threatening etiologies, ranging from functional pain to acute appendicitis.
• The majority of pediatric abdominal complaints are relatively benign (e.g. constipation),
but it is important to pick up on the cardinal signs that might suggest a more
serious underlying disease.
• Diagnosing abdominal pain in children is also a challenging task. Conditions vary
amongst age groups ( i.e. volvulus in neonates, intussusception in toddlers) and trying
to thoroughly evaluate a child in pain can make the process all the more challenging.
 BASIC ANATOMY AND PHYSIOLOGY
• When taking a history and examining a child with abdominal pain, consider all
the organs in the abdominal area.
• Pathologies of the lower lung (i.e. pneumonia) can often be interpreted as
abdominal pain; similarly, genitourinary pathology (i.e. testicular torsion) can be
as well.
• A sharp stabbing pain may suggest somatic involvement – this type
of sensation is usually well localized; while dull, non-specific, throbbing
pain suggests visceral involvement that is difficult to localize.
• Remember, the differential diagnosis of a child varies
depending on their age group.
 PRESENTATION AND EMERGENT
CONSIDERATIONS
• Acute pain lasts several hours to days while chronic pain can last from days to weeks to
months. In a child presenting with abdominal pain, it is important to identify any
emergent concerns and reach a timely diagnosis.
Red flag signs include:
• · Bilious vomiting
• · Bloody stool or emesis
• · Night time waking with abdominal pain
• · Hemodynamic instability
• · Weight loss
 Questions to
Ask?
HISTORY
Mnemonics PQRSTAAA:
o Place/Location: identify the specific location of the pain, have child use
one finger to locate her pain.
o Quality: pain can be a sharp stabbing pain (i.e. trauma) or diffuse,
poorly, localized pain (i.e. chronic or visceral pain)
o Radiation: pain can radiate from its point of origin in any direction
o Severity: degree of pain on a scale of 10
HISTORY: Continued

o Timing/Onset: onset of the pain, duration of pain, course during the day, does it
wake them at night, and the frequency of episodes
o Alleviating Factors: anything that reduces the pain – body position, movements
(or lack thereof), medications.
o Aggravating Factors: anything that increases the pain – body
position, movements, relation to food intake.
o Associated Symptoms: can include hematemesis, vomiting, nausea,
hematochezia, melena, diarrhea, fever, and weight loss
HISTORY: Continued

 Ask about bowel movement patterns and stool quality (size, hard/soft, odour).
 Ask about ingestion of toxin or foreign object; accidental or non-accidental trauma
 Ask about dietary history: in young children, too much milk can lead to
constipation.
 Ask about past medical history and medical
comorbidities. Cystic fibrosis predisposes to gallstones.
Spina bifida/cerebral palsy/developmental delay
predisposes to constipation.
Sickle cell disease predisposes to splenic auto-infarction.
Recurrent respiratory tract infections suggest mesenteric
HISTORY: Continued
 Ask about sexual history – screen for STI
• Females: don’t forget about menstrual cycles (regularity, amount of
bleeding,
relation to abdominal pain)
 Ask about family medical history, especially inflammatory bowel disease.
 Ask about travel history, social and psychiatric (potential stressors) history.
 Physical Exam and
Investigations
PHYSICAL EXAM:
• ABCs; vitals; and growth parameters (is there evidence of failure to thrive).
• Inspection: look for contour, symmetry, pulsations, peristalsis, vascular
irregularities,
skin markings, wall protrusions (hernias), any signs of trauma (Ie.
bruising, swelling),
and abdominal distension
• Palpation: assess tenderness with light and deep palpation, assess for guarding
and rebound tenderness, palpate for liver, spleen, kidney and abdominal masses
(including fecal mass).
PHYSICAL EXAM: continued
• Percussion: assess general tone (tympanic vs non-tympanic), percuss for liver
span
and spleen tip, assess for ascites (find edge of percussion tone change).

• Auscultation: auscultate before palpation in the abdominal exam, listen for

bowel sounds, abdominal bruits, pressure of the stethoscope also tests for
tenderness
• Digital rectal exam: first exam the anus for fissures and skin tags, then assess
for
tone, stool, and blood.
 Key
points:
1. Determine if abdominal pain is acute or
chronic
2. Is the abdomen acute/surgical or benign
3. Are red flags present